Provider Demographics
NPI:1730768417
Name:CORNELL, MIRIAM WHITNEY (LMFT)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:WHITNEY
Last Name:CORNELL
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3790 VAN DYKE ST
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-4740
Mailing Address - Country:US
Mailing Address - Phone:612-280-6239
Mailing Address - Fax:
Practice Address - Street 1:1000 COUNTY ROAD E W
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-8054
Practice Address - Country:US
Practice Address - Phone:612-254-5963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3738106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist